Provider Demographics
NPI:1740389873
Name:ILLARI, JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:ILLARI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 CLEREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-1708
Mailing Address - Country:US
Mailing Address - Phone:631-382-7793
Mailing Address - Fax:631-382-7786
Practice Address - Street 1:269 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2832
Practice Address - Country:US
Practice Address - Phone:631-382-7793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00433655Medicare PIN
NYQA49585961Medicare PIN